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Demystifying claims in the health insurance policy


Health insurances act as financial support to people in the event of a medical emergency. However, filing claims can be a difficult and time-consuming process. One thing that can make the whole claims process easier is knowing all the essential information in advance to avoid last minute surprises. The two types of claims that are accessible and must be familiar with each insured are:

Cashless Claims

When it comes to cashless claims, insurance companies pay directly to the hospital where there is no waiting period for reimbursement. An insured can only opt for a cashless claim if he is treated in a hospital of the insurer’s network. In order to benefit from cashless services, the policyholder must inform the insurer 3 to 4 days before admission to the hospital and must complete the pre-authorization form. In an emergency, a prompt notice to the insurer will also work, but the pre-authorization form must be completed within 24 hours of hospitalization.

Refund requests

Some plans do not provide a cashless claim mechanism and insureds must reimburse expenses. Reimbursement can also be requested if the insured is treated in an off-grid hospital or if he has not opted for cashless payment.

To benefit from reimbursement request services, the policyholder must inform the insurer and submit the duly completed reimbursement request form within 30 days of the date of discharge from hospital. The policyholder will also need to submit original copies of all invoices and medical reports along with the claim form. The medical reports must clearly mention the name of the patient and the date which must be attached with the doctor’s prescription to show that the hospitalization or the medical prescriptions were not voluntary but according to the doctor’s opinion.

Once a policyholder is aware of the different types of claims, it is essential to understand the various aspects of their insurance. This includes information such as the maximum amount for which a claim can be made, a list of treatments that can and cannot be covered by insurance, and other aspects which are discussed in more detail below.

Sum insured Limit

Health insurance claims are only allowed up to the sum insured. The sum insured is the maximum value for a year that your insurance company can pay in the event of hospitalization. In addition to the sum insured, a policy may also have limits for coverage of room rent and intensive care costs. Therefore, it is important to be aware of these limitations when filing a claim.

Exclusions

Treatments for which the insurance company does not provide coverage are called exclusions. As a result, insurance companies will deny claims for these exclusions. Intentional injuries, congenital diseases, HIV, are some examples of exclusions from health coverage. The list of exclusions may be different for different insurers and even for different policies of the same insurer.

Submission deadlines

There is a deadline for submitting the pre-authorization form to make a cashless claim. In case of planned treatment, the pre-authorization form must be submitted 3 to 4 days in advance while in case of emergency, the form must be submitted within 24 hours of hospitalization.

If the form is not submitted on time, the complaint may be delayed, resulting in a delay in processing, if you opt for a cashless complaint.

List of network hospitals

In the event that an insured wishes to opt for a cashless claim, he must know the entire network of hospitals covered by his insurance. The best thing to do is to keep a list of network hospitals handy in an emergency or in general.

The validity of the insurance policy

Medicare claims are only applicable if the health plan is valid. If a health insurance policy has expired, the claim will be rejected by the insurance company. Thus, to avoid any inconvenience in an emergency, you must ensure that your insurance policy is correctly updated.

Waiting times

When it comes to covering pre-existing conditions or specific conditions, different health insurance policies offer varying wait times. Therefore, it is essential to know the different waiting times that accompany a policy in order to avoid misunderstandings in an emergency.

Now that we’ve covered all the important clauses, we can move on to the last part of filing a successful claim – making sure that we have all the necessary documents.

Documents required for a successful claim

The claims process involves a lot of paperwork. Here is a list of documents that one may need to file a successful claim:

● Medical bills

● Medical reports

● Pre-authorization form

● Valid proof of identity of the insured

● Copy of the deposit of the insurance policy

● Canceled check

Besides the above list, insurance companies may have other document requirements. Policyholders can request in advance the list of documents required from their insurer to prepare for any health emergency.

Filing claims can be a tedious process, but it can be made easier if the policyholder is aware of all the different clauses and documentary requirements of his health insurance. Staying informed of basic complaints terminology can help ensure a hassle-free complaints experience in an emergency.

The author, Saransh Garg, is co-founder and CEO of Nova Benefits. Opinions expressed are personal

(Edited by : Anshul)

First publication: STI


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